U.S. patent application number 17/103828 was filed with the patent office on 2021-04-08 for predictive medication safety.
The applicant listed for this patent is CareFusion 303, Inc.. Invention is credited to Federico GARIBALDI, Vikas GUPTA, Scott LOEBIG, Timothy W. VANDERVEEN.
Application Number | 20210103871 17/103828 |
Document ID | / |
Family ID | 1000005278094 |
Filed Date | 2021-04-08 |
United States Patent
Application |
20210103871 |
Kind Code |
A1 |
GUPTA; Vikas ; et
al. |
April 8, 2021 |
PREDICTIVE MEDICATION SAFETY
Abstract
A system and method for facilitating safe use of a medical
device is provided. In one aspect, a method includes receiving an
indication that a user has entered a set of parameters into a
medical device to provide a medical treatment to a patient,
receiving a history of previous medical treatment provided to the
patient using the medical device, generating one or more
alternative parameters for providing the medical treatment to the
patient based on the set of parameters and the received history of
previous medical treatment, causing, based on the generating of the
one or more alternative parameters, a locking of the medical device
to restrict operation of the medical device until an override of
the lock is received, providing a notification for display to the
user regarding the alternative parameters.
Inventors: |
GUPTA; Vikas; (Naperville,
IL) ; LOEBIG; Scott; (Encinitas, CA) ;
GARIBALDI; Federico; (Encinitas, CA) ; VANDERVEEN;
Timothy W.; (Poway, CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
CareFusion 303, Inc. |
San Diego |
CA |
US |
|
|
Family ID: |
1000005278094 |
Appl. No.: |
17/103828 |
Filed: |
November 24, 2020 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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15682428 |
Aug 21, 2017 |
10867265 |
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17103828 |
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13802683 |
Mar 13, 2013 |
9741001 |
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15682428 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
G06Q 50/22 20130101;
G16H 40/67 20180101; G16H 20/13 20180101; G16H 20/17 20180101; G16H
70/40 20180101; G06Q 10/06 20130101; G06Q 10/06313 20130101 |
International
Class: |
G06Q 10/06 20060101
G06Q010/06; G16H 20/13 20060101 G16H020/13; G16H 20/17 20060101
G16H020/17; G16H 40/67 20060101 G16H040/67; G06Q 50/22 20060101
G06Q050/22 |
Claims
1. A medical device monitoring system, comprising: one or more
processors; and a non-transitory computer-readable memory storing
instructions thereon that, when executed, cause the one or more
processors to execute a monitoring application and perform
operations comprising: receiving an indication that a user has
entered a set of parameters into a medical device to provide a
medical treatment to a patient; receiving, from a system remote
from the medical device, responsive to the indication and prior to
providing the treatment to the patient, a history of previous
medical treatment provided to the patient using the medical device;
generating one or more alternative parameters for providing the
medical treatment to the patient based on the set of parameters
entered into the medical device and the received history of
previous medical treatment provided to the patient using the
medical device; and causing, based on the generating of the one or
more alternative parameters, a locking of the medical device to
restrict operation of the medical device until an override of the
lock is received; providing a notification for display to the user
regarding the alternative parameters; and providing, when the
alternative parameters are confirmed or overridden, a signal to the
medical device to begin providing the treatment to the patient.
2. The medical device monitoring system of claim 1, wherein the
medical device is an infusion device, and the medical treatment is
an administration of a medication by the infusion device, and the
one or more alternative parameters are medication delivery
parameters for delivering the medication to the patient.
3. The medical device monitoring system of claim 2, wherein the
history of previously medical treatment comprises medication
delivery parameters previously entered into the infusion
device.
4. The medical device monitoring system of claim 2, wherein the
operations further comprise: receiving, from the system remote from
the medical device, responsive to the indication and prior to
providing the medical treatment, a history of the user with regard
to usage of the infusion device and an amount of the medication
previously administered by the user.
5. The medical device monitoring system of claim 1, wherein the
operations further comprise: receiving, from the system remote from
the medical device, responsive to the indication and prior to
providing the medical treatment, a history of the user with regard
to medical treatment provided to the patient, or use of the medical
device.
6. The medical device monitoring system of claim 5, wherein the
history of the user comprises an identification of one or more
errors made by the user with the medical device or the patient.
7. The medical device monitoring system of claim 1, further
comprising a memory storing a list of drugs and drug
recommendations, wherein the operations further comprise: receiving
patient information for the patient; receiving a selection of a
drug from the list of drugs; reviewing a respective recommendation
for the selected drug of the list of drugs, relative to the patient
information for the patient; and providing an additional
recommendation for administration of the selected drug based on the
review, the additional recommendation including a drug dosage,
dosage limit, infusion rate, or infusion time.
8. The medical device monitoring system of claim 1, further
comprising: an information system communicatively coupled to a
medication order system, wherein the information system is
configured to store a list of drugs and to provide a subset of the
list of drugs together with a recommendation for administration for
each drug in the subset of the list of drugs to the order
system.
9. A non-transitory machine-readable storage medium comprising
machine-readable instructions for causing a processor to execute a
method, the method comprising: receiving an indication that a user
has entered a set of parameters into a medical device to provide a
medical treatment to a patient; receiving, from a system remote
from the medical device, responsive to the indication and prior to
providing the treatment to the patient, a history of previous
medical treatment provided to the patient using the medical device;
generating one or more alternative parameters for providing the
medical treatment to the patient based on the set of parameters
entered into the medical device and the received history of
previous medical treatment provided to the patient using the
medical device; and causing, based on the generating of the one or
more alternative parameters, a locking of the medical device to
restrict operation of the medical device until an override of the
lock is received; providing a notification for display to the user
regarding the alternative parameters; and providing, when the
alternative parameters are confirmed or overridden, a signal to the
medical device to begin providing the treatment to the patient.
10. The non-transitory machine-readable storage medium of claim 9,
wherein the medical device is an infusion device, and the medical
treatment is an administration of a medication by the infusion
device, and the one or more alternative parameters are medication
delivery parameters for delivering the medication to the
patient.
11. The non-transitory machine-readable storage medium of claim 10,
wherein the history of previously medical treatment comprises
medication delivery parameters previously entered into the infusion
device.
12. The non-transitory machine-readable storage medium of claim 10,
wherein the method further comprises: receiving, from the system
remote from the medical device, responsive to the indication and
prior to providing the medical treatment, a history of the user
with regard to usage of the infusion device and an amount of the
medication previously administered by the user.
13. The non-transitory machine-readable storage medium of claim 9,
wherein the method further comprises: receiving, from the system
remote from the medical device, responsive to the indication and
prior to providing the medical treatment, a history of the user
with regard to medical treatment provided to the patient, or use of
the medical device.
14. The non-transitory machine-readable storage medium of claim 13,
wherein the history of the user comprises an identification of one
or more errors made by the user with the medical device or the
patient.
15. The non-transitory machine-readable storage medium of claim 9,
further comprising a memory storing a list of drugs and drug
recommendations, wherein the method further comprises: receiving
patient information for the patient; receiving a selection of a
drug from the list of drugs; reviewing a respective recommendation
for the selected drug of the list of drugs, relative to the patient
information for the patient; and providing an additional
recommendation for administration of the selected drug based on the
review, the additional recommendation including a drug dosage,
dosage limit, infusion rate, or infusion time.
16. A method, comprising: receiving an indication that a user has
entered a set of parameters into a medical device to provide a
medical treatment to a patient; receiving, from a system remote
from the medical device, responsive to the indication and prior to
providing the treatment to the patient, a history of previous
medical treatment provided to the patient using the medical device;
generating one or more alternative parameters for providing the
medical treatment to the patient based on the set of parameters
entered into the medical device and the received history of
previous medical treatment provided to the patient using the
medical device; and causing, based on the generating of the one or
more alternative parameters, a locking of the medical device to
restrict operation of the medical device until an override of the
lock is received; providing a notification for display to the user
regarding the alternative parameters; and providing, when the
alternative parameters are confirmed or overridden, a signal to the
medical device to begin providing the treatment to the patient.
17. The method of claim 16, further comprising: receiving patient
information for the patient; receiving a selection of a drug from
the list of drugs; reviewing a respective recommendation for the
selected drug of the list of drugs, relative to the patient
information for the patient; and providing an additional
recommendation for administration of the selected drug based on the
review, the additional recommendation including a drug dosage,
dosage limit, infusion rate, or infusion time
18. The method of claim 16, wherein the medical device is an
infusion device, and wherein the method further comprises:
receiving, from the system remote from the medical device,
responsive to the indication and prior to providing the medical
treatment, a history of the user with regard to usage of the
infusion device and an amount of the medication previously
administered by the user.
19. The method of claim 16, further comprising: receiving, from the
system remote from the medical device, responsive to the indication
and prior to providing the medical treatment, a history of the user
with regard to medical treatment provided to the patient, or use of
the medical device.
20. The method of claim 19, wherein the history of the user
comprises an identification of one or more errors made by the user
with the medical device or the patient.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] The present application claims the benefit of priority under
35 U.S.C. .sctn. 120 as a continuation of U.S. patent application
Ser. No. 15/682,428, entitled "Predictive Medication Safety," filed
Aug. 21, 2017, which is a continuation of U.S. patent application
Ser. No. 13/802,683, entitled "Predictive Medication Safety," filed
Mar. 13, 2013, now U.S. Pat. No. 9,741,001, issued on Aug. 22,
2017, the disclosures of which are hereby incorporated by reference
in their entirety for all purposes.
BACKGROUND
Field
[0002] The present disclosure generally relates to medical devices,
and particularly to configuring medical devices to reduce
error.
Description of the Related Art
[0003] Medication errors, that is, errors that occur in the
ordering, dispensing, and administration of medications, regardless
of whether those errors cause injury or not, are a significant
consideration in the delivery of healthcare in the institutional
setting. Additionally, adverse drug events (ADE), which are defined
as injuries involving a drug that require medical intervention and
are a subset of medication errors, represent some of the most
serious medication errors are responsible for a number of patient
injuries and death.
[0004] Healthcare facilities continually search for ways to reduce
the occurrence and severity of medication errors. Various systems
and methods are commonly used to reduce the frequency of occurrence
and severity of preventable adverse drug events (PADE) and other
medication errors. In the administration of medication, focus is
typically directed to the following five "rights" or factors: the
right patient, the right drug, the right route, the right amount,
and the right time. Systems and methods seeking to reduce ADEs and
PADEs should take these five rights into consideration.
[0005] Delivery, verification, and control of medication in an
institutional setting have traditionally been areas where errors
can occur. In a typical healthcare facility, a physician enters an
order for a medication for a particular patient. This order may be
handled either as a simple prescription slip, or it may be entered
into an automated system, such as a physician order entry (POE)
system. The prescription slip or the electronic prescription from
the POE system is routed to the pharmacy, where the order is
filled. Typically, pharmacies check the physician order against
possible allergies of the patient and for possible drug
interactions in the case where two or more drugs are prescribed,
and also check for contraindications. Depending on the healthcare
facility, the medication may be identified and gathered within the
pharmacy and placed into a transport carrier for transport to a
nurse station. Once at the nurse station, the prescriptions are
again checked against the medications that have been identified for
delivery to ensure that no errors have occurred. Each of these
steps or workflows is typically captured as event data in a
hospital information system. The event data is not, however, used
to adjust future workflows involving medical items. For example, a
medical item from a dispensing cabinet may have an associated
warning related to how commonly the medical item is wasted. This
information is not, however, used to adjust future workflows from
reducing waste of the medical item.
SUMMARY
[0006] According to one embodiment of the present disclosure, a
method for facilitating safe use of a medical item is provided. The
method includes receiving a first identifier for a medical entity
located in an institution. The medical entity includes at least one
of a patient, medical device, medical location, or medical item.
The method also includes receiving a second identifier for a first
course of action associated with the medical entity. The method
further includes generating, based on a history of the medical
entity and the first course of action associated with the medical
entity, a second course of action for the medical entity, and
providing a notification to a device indicating the second course
of action.
[0007] According to another embodiment of the present disclosure, a
monitoring system for facilitating safe use of a medical item is
provided. The system includes a memory that includes a history of a
medical entity located in an institution. The medical entity
includes at least one of a patient, medical device, medical
location, or medical item. The system also includes a processor.
The processor is configured to receive a first identifier for the
medical entity and a second identifier for a first course of action
associated with the medical entity, and generate, based on a
history of the medical entity and the first course of action
associated with the medical entity, a second course of action for
the medical entity. The processor is also configured to provide a
notification to a device indicating the second course of
action.
[0008] According to a further embodiment of the present disclosure,
a machine-readable storage medium that includes machine-readable
instructions for causing a processor to execute a method for
facilitating safe use of a medical item is provided. The method
includes receiving a first identifier for a medical entity located
in an institution. The medical entity includes at least one of a
patient, medical device, medical location, or medical item. The
method also includes receiving a second identifier for a first
course of action associated with the medical entity. The method
further includes generating, based on a history of the medical
entity and the first course of action associated with the medical
entity, a second course of action for the medical entity, and
providing a notification to a device indicating the second course
of action.
[0009] According to yet a further embodiment of the present
disclosure, a method for instructing a caregiver is provided. The
method includes receiving a first identity of a caregiver at an
institution and a proposed course of action for a medical entity,
and generating, based on a history of the caregiver within the
institution, a modified course of action. The method also includes
providing a notification of the modified course of action to the
caregiver.
[0010] It is understood that other configurations of the subject
technology will become readily apparent to those skilled in the art
from the following detailed description, wherein various
configurations of the subject technology are shown and described by
way of illustration. As will be realized, the subject technology is
capable of other and different configurations and its several
details are capable of modification in various other respects, all
without departing from the scope of the subject technology.
Accordingly, the drawings and detailed description are to be
regarded as illustrative in nature and not as restrictive.
BRIEF DESCRIPTION OF THE DRAWINGS
[0011] The accompanying drawings, which are included to provide
further understanding and are incorporated in and constitute a part
of this specification, illustrate disclosed embodiments and
together with the description serve to explain the principles of
the disclosed embodiments. In the drawings:
[0012] FIG. 1 illustrates a block diagram of a system for
facilitating safe use of a medical item.
[0013] FIG. 2 is a block diagram illustrating the monitoring system
and server from the architecture of FIG. 1 according to certain
aspects of the disclosure.
[0014] FIG. 3 illustrates an example process for facilitating safe
use of a medical item using the example monitoring system of FIG.
2.
[0015] FIG. 4 is an example illustration of a medical item, namely
a medical device, associated with the example process of FIG.
3.
[0016] FIG. 5 is a block diagram illustrating an example computer
system with which the clients and server of FIG. 2 can be
implemented.
DETAILED DESCRIPTION
[0017] In the following detailed description, numerous specific
details are set forth to provide a full understanding of the
present disclosure. It will be apparent, however, to one ordinarily
skilled in the art that the embodiments of the present disclosure
may be practiced without some of these specific details. In other
instances, well-known structures and techniques have not been shown
in detail so as not to obscure the disclosure.
[0018] Each of the steps of a workflow related to a medical entity,
such as a patient, medical device, medical location, or medical
item, can be captured as event data in a hospital information
system. The event data can be, for example, historical data related
to the medical entity. The disclosed system leverages the event
data for the medical entity to determine, for example, whether to
suggest an alternative workflow for the medical entity. For
instance, event information for a medication from a dispensing
cabinet may be evaluated by the disclosed system to determine a
percentage of times the medication is wasted. The disclosed system
may then send a notification to a caregiver attempting to dispense
the medication regarding the potential wastage, and may further
restrict the caregiver from dispensing the medication until
additional verification steps are taken. Similar notifications and
workflow suggestions can be suggested for improving a health level
of a patient, expediting dispensing of a medical item, indicating
an incidence rate of illness in a medical location, or a
recommending an increase of an order being placed for medical items
based on a recent change in demand for the medical item. The
notifications and other workflow suggestions can be specific to the
caregiver specific when, for example, an abnormal utilization
pattern for a medical item is specific to the caregiver.
[0019] Several examples will now be presented regarding how the
disclosed system can assist a caregiver in facilitating a safe
interaction with a medical entity. As one example, a notification
can be sent if a certain medication is continuously used to address
a certain pathology when it is shown that the patient length of
stay is not improved over time using that medication. As another
example, a specific nurse can be alerted to check on order
information if the nurse is historically hitting safe or
therapeutic limits on doses too often. As yet another example, a
specific caregiver can be informed that the caregiver's level of
drug waste is high on average. As a further example, a pharmacist
can be informed that a certain medication may be required statim
(e.g., "stat" or urgently) because the medication has historically
taken a long time to be delivered to a patient.
[0020] Referring now to the drawings, FIG. 1 provides an example
illustration of an integrated healthcare facility-wide information
and care management system 28 in accordance with certain aspects of
the present disclosure. Various subsystems of a healthcare
facility's information management system are connected together by
way of a facility communication system 30. The communication system
30 may include, for example, any one or more of a personal area
network (PAN), a local area network (LAN), a campus area network
(CAN), a metropolitan area network (MAN), a wide area network
(WAN), a broadband network (BBN), the Internet, and the like.
Further, the communication system 30 can include, but is not
limited to, any one or more of the following network topologies,
including a bus network, a star network, a ring network, a mesh
network, a star-bus network, tree or hierarchical network, and the
like. As shown in FIG. 1, the communication system 30 connects
through various interfaces 32 to a healthcare facility information
system 34, a pharmacy information system 36, a physician order
entry system 38, a medical entity database 60, and a monitoring
system 40.
[0021] The facility communication system 30 is not meant to be
taken in a limited sense. Such a facility communication system 30
may encompass an entire healthcare facility or may be located only
in a small area of the healthcare facility. It may also include a
communication system in a healthcare facility other than a hospital
and may have application to an alternate care facility, such as a
patient's home. Additionally, the word caregiver is intended to be
used in its broadest sense and is meant to include nurses,
physicians, health care specialists, and others who provide care to
patients.
[0022] The monitoring system 40 in accordance with an aspect of the
present disclosure may be, for example, a server or other computer
having sufficient memory 42 and processing capability to connect
with the communication system 30 and determine a change in workflow
for a healthcare process. The monitoring system 40 includes
operational software or other instructions for carrying out various
aspects of the present disclosure, as will be discussed more fully
below, enabling communications with other hardware or networks, and
data input and output and report generation and printing, among
other functions. While the monitoring system 40 is shown as a
separate piece of equipment, it will be understood that the
monitoring system 40 and the associated memory 42 may also be
incorporated into another element, such as the medical device
80.
[0023] The communication system 30 may comprise, for example, a
wired or wireless Ethernet (IEEE 522.3) utilizing transmitters and
receivers positioned throughout the healthcare facility and/or
attached to various computers, clinical devices and other equipment
used in the facility. In such a wireless system, the signals
transmitted and received by the system could be radio frequency
(RF), infrared (IR), or other means capable of carrying information
in a wireless manner between devices having appropriate
transmitters or receivers may be used. It will be immediately
understood by those skilled in the art that such a system may be
identical to the system set forth in FIG. 1, with the exception
that no wires are required to interconnect the various aspects of
the system.
[0024] In a typical healthcare facility, patient rooms, wards, or
areas are typically situated in groups located near a nurse station
44, where the caregivers assigned to care for the patients in the
particular area carry out the administrative functions of their
duties. Typically, these functions include updating and monitoring
the patients' charts, preparation of and administering medication
orders, and monitoring and recording any other information deemed
necessary by the facility for tracking. There is also usually a
room located adjacent the nurse station that is dedicated to
storage and/or the preparation of medications to be delivered to
patients. This room may contain inventories of commonly used oral,
IM, or IV medications. The room may also be used to formulate the
contents of infusion bags in accordance with prescribed treatment
regimens.
[0025] The nurse station 44 will typically include a terminal or
computer system 46 connected either directly or through an
interface 48 to the communication system 30, allowing users at the
nurse station to enter and retrieve patient data or information
from other systems, such as the healthcare facility information
system 34, the pharmacy information system 36, the physician order
entry system 38, or other systems used in the facility. It should
be understood that not all users will be provided with access
rights to each system. For example, physicians may be able to
access the physician order entry system 38 from the nurse station
system 44 to enter, edit, or track medication orders, but a
caregiver may only be able to view such orders. Moreover, while the
present disclosure is described with reference to the computer
system 46 being located at a nurse station 44, the computer system
46 may also be a satellite system that is located anywhere in the
care-giving facility where it is convenient or efficient to do so.
Such a satellite computer system may be operably connected to the
communication system 30 using either a wired or wireless network
connection. A printer 50 may also be connected to the nurse station
computer system 46 for printing reports, bar codes, labels, or
other materials, and a bar code reader 52 may be provided for
reading bar codes on medication labels, reports, or other items
having bar coded labels provided for identification.
[0026] In a different embodiment where radio frequency
identification (RFID) tags are used with medications, patients,
equipment, or in other ways, the nurse station 44 may also include
an interrogator or RFID reader (not shown) for use with the RFID
tags.
[0027] In accordance with aspects of the present disclosure, a
medical entity database 60 stores information related to medical
entities, such as patients, medical devices, medical locations, and
medical items. Various types of information may be stored in the
memory of the medical entity database 60, including medical item
history and course of action information (e.g., orders, history of
use, caregivers associated with the item, etc.). Databases can also
be stored in the database 60 that contain information about drug
interactions and possible contraindications and/or side-effects of
medications, and established guidelines for the administration of
various medications. For example, the guidelines may include
institutionally-established guidelines or limits on drug
administration parameters, such as dosage, frequency of
administration, and other delivery related information such as, for
example, appropriate flow rates and infusion durations for
programming infusion pumps. Additionally, the guidelines may
encompass guidelines for providing drug administration appropriate
to a particular patient or to treatment areas having different sets
of delivery parameters for similar medications, such as medication
administration directed to geriatric, pediatric, and oncology
patients. Guidelines may also be included that are directed to
particular therapy regimens, such as chemotherapy regimens or
regimens for treating chronic infection or pain. The term database
as used herein will be understood by those skilled in the art to be
used as is commonly understood. That is, the term database refers
to a collection of values or information organized, formatted, and
stored in such a manner as to be capable of being retrieved and
analyzed using an appropriate program contained in software or
other form.
[0028] The medications guidelines database 60 may be stored on a
device, such as a server. The healthcare facility may also or
alternatively have the medical entity database 60 centrally located
in the memory 42 of the monitoring system 40. The medical entity
database 60 includes medication information, medical item history,
and course of action information, and/or databases or libraries,
including institutionally generated guidelines for the delivery of
medication to a patient, as well as drug interaction information or
information concerning possible drug side-effects. The medications
guidelines database 60 may also have a storage capability and
technology for interfacing with a computer system or network so
that information may be communicated between the medications
guidelines database 60 and other devices, such as computers,
medication administration devices, clinical devices such as vital
signs monitoring devices and the like. A general concept embodied
in the medications guidelines database 60 is to provide safe
medication guidelines for dispensing, administering, or otherwise
providing medication a patient using, for example, a medical device
80 such as an infusion pump.
[0029] In accordance with aspects of the present disclosure, the
monitoring system 40 is configured to obtain medical entity
information from the medical entity database 60. The medical entity
database 60 is configured to obtain device information from the
medical device 80, previous medical item history and course of
action information (e.g., orders, history of use, caregivers
associated with the item, etc.) from physician order entry system
38, the pharmacy information system 36, and the healthcare facility
information system 34. Information may be retrieved information
from the medical device 80 prior to actual medication
administration. Monitoring system 40 can determine, based on a
history of a medical entity and a current course of action for the
medical entity, whether an alternative course of action should be
taken for the medical entity. If the determination indicates an
alternative course of action should be taken, then the monitoring
system 40 is configured to transmit a notification to a relevant
caregiver or device indicating the alternative course of action.
The monitoring system 40 may also restrict or otherwise inhibit the
current course of action from being taken (e.g., by locking a
device).
[0030] For example, physician order system 38 may indicate that a
certain medication is to be provided to a patient, and the pharmacy
information system 36 may indicate how often the medication has
been dispensed to the patient in the past. Based on this
information, the monitoring system 40 may determine that dispensing
the medication to the patient is harmful according to certain
medical guidelines (e.g., from medical entity database 60). The
monitoring system may then prevent a medical device 80 from
dispensing the medication by locking the medical device 80 and
possibly requiring a manual override of the lock in order to
dispense the medication to the patient.
[0031] As another example, the pharmacy information system 36 may
indicate that an order for 30 doses of a medication is to be
placed, and the healthcare facility information system 34 may
indicate that an incidence of an illness (e.g., with reference to
patient laboratory data) that is treated by the medication has
increased sharply in the past 24 hours. Based on the order and
incidence information, the monitoring can send a notification to
the pharmacy information system 36 to increase the number of doses
being ordered, and may provide a suggested amount based on the
incidence information.
[0032] As yet a further example, the healthcare facility
information system 34 may include a caregiver's history regarding
medication and medical device usage, and the medical entity
database 60 may indicate an appropriate amount of a medication the
caregiver has given in the past. The monitoring system 40 may
determine that the amount of the medication the caregiver has given
in the past has been inadequate, and send a notification to the
medical device 80 or another device of the caregiver indicating
that the medication amount provided by the caregiver should be
increased.
[0033] While specific examples of a monitoring system 40 are set
forth herein, it will be understood that the monitoring system 40
is meant to include any device that carries out the basic concept
of the disclosure. That is, a device that receives an
identification of a medical entity, such as a patient, medical
device, medical location, or medical item, and an identification of
a course of action associated with the medical entity, and has a
processor that generates, based on a history of the medical entity
and the course of action associated with the medical entity, a
second (e.g., alternative) course of action for the medical entity,
and provides a notification to a device (e.g., device of a
caregiver, medical device 80, physician order entry system 38,
pharmacy information system 36, healthcare facility information
system 34) indicating the second course of action.
[0034] One particular mode of operation of the present disclosure
will now be described. A patient entering a healthcare facility is
provided with a wrist band, necklace, ankle band, or other band,
chain, or device designed to remain affixed to or embedded in the
patient during the patient's entire stay in the healthcare facility
(the "patient ID"). The patient ID is designed to remain affixed in
a manner so that the patient can be identified even if unconscious
or otherwise unresponsive. The patient ID is used to identify
specific patient data, such as the patient's name and other
information that the facility has determined is important, such as
age, allergies, or other vital information. The patient identifying
device may comprise a bar code, written information, or an
electronic information storage device, such as an RF transponder
(e.g., RFID tag), that contains the information, or other device
affixed to the patient. In the case where the patient-specification
information may also include the patient's medication
administration record (MAR). This would allow for consistent
documentation and also checks against drug interaction in the
medical entity database 60.
[0035] Such RFID tags, barcodes, and other technologies useful in
identification, may be applied to others and to other things in
providing healthcare to patients. For example, physicians, nurses,
and other caregivers, as well as others who have access to patients
and facilities, may also have an RFID tag that can be read anywhere
in the healthcare facility. The medical fluid containers may
contain RFID tags having information about the contents of the
container as well as the patient for whom they have been prepared,
the pharmacist who prepared them, and the physician who prescribed
them. The infusion pumps and other healthcare instruments and
devices may have RFID tags useful for inventory control. Even
though the instruments may be connected to the healthcare facility
communication system 30, RFID tags can be useful for manual
inventory purposes as well as for other purposes. Their low cost
makes them attractive as a backup support system.
[0036] After the patient is admitted and situated in a bed within
the facility, the patient is typically evaluated by a physician and
a course of treatment is prescribed. The physician prescribes a
course of treatment by preparing an order that may request a series
of laboratory tests or the administration of a particular
medication to the patient. In some cases, the physician prepares
the order by filling in a form or writing the order on a slip of
paper to be entered into the healthcare facility system for
providing care. In other cases, the physician may enter the
medication order directly into a physician order entry system 38 or
may instruct a nurse or other care-giving professional to do so. In
yet another case, the physician may use the Internet to forward and
enter a prescription for the patient into the pharmacy system.
Depending on the arrangement at the healthcare facility, the
physician's order or prescription may directly reach a website for
the pharmacy information system 36 or may go to a website for the
healthcare facility where it may then be routed to the pharmacy
information system 36. In certain aspects, the monitoring system 40
may review the prescribed course of treatment for the patient and
the history of prescriptions by the physician or other physicians,
and propose an alternative treatment for the patient to the
physician for review.
[0037] Pharmacy information systems 36 may enable a safer physician
medication order process. The pharmacy information system 36 may
provide the physician with a list of available drugs from which the
physician may select. The pharmacy information system 36 may
contain a drug library having the list of available drugs but may
also contain and present to the physician the drug names associated
with recommended dosages and dose limits that have been established
or adopted by the healthcare facility. In such a case where the
physician need only select items from the computer screen rather
than having to manually type in drug names and drug administration
numbers (such as infusion rates, times, etc.) associated with
administration of the medication, a more accurate medication
process should result.
[0038] If the order is for administration of a particular
medication regimen, the order will be transmitted to the facility's
pharmacy information system 36. The pharmacy reviews the order. In
certain aspects, the monitoring system 40 may, for example, review
the particular medication regimen for the patient and the history
of medication regimens for the patient or similar patients, and
then propose an medication regiment for the patient to the
pharmacist (or physician) for review.
[0039] The pharmacy prepares the medication according to the
requirements of the physician. Typically, the pharmacy packages the
medication in a container, and a copy of the order, or at a minimum
the patient's name, the drug name, and the appropriate treatment
parameters are represented on a label or other device that is
affixed to the drug container. This information may be represented
by a bar code, or it may be stored in a smart label, such as a
label having an embedded computer, or in a passive device such as
an RFID tag discussed above.
[0040] Once the order has been prepared, the order is sent to the
nurse station 44 for matching with the appropriate patient.
Alternatively, if the medication is for a commonly or routinely
prescribed medication, the medication may be included in an
inventory of medications that is stored in a secure cabinet
adjacent the nurse station 44. In such a case, the nurse station 44
will receive a list of orders from the pharmacy information system
36 that may be drawn from the inventory adjacent the nurse station
44. The caregiver will enter a unique identifier at the cabinet to
gain access in accordance with standard practice. The caregiver or
other professional assigned the task of gathering medications will
then match the orders received from the pharmacy information system
60 to the medications stored in the inventory and pull those
medications that are to be delivered to specific patients. These
procedures are carried out whether the medication to be delivered
is an oral medication or a medication that is to be delivered
intramuscularly or through an infusion. In certain aspects, the
monitoring system 40 may review the medication orders to determine,
for example, whether the caregiver has a particularly high level of
waste for the medication order being dispensed. If such a
determination is made, the monitoring system 40 may send a
notification to the nurse station 44 for the caregiver to view. The
notification can state, for example, the caregiver's recorded
history of waste and either remind the caregiver to be careful in
dispensing the medication order, or propose an alternative workflow
to dispensing the medication order.
[0041] In certain circumstances, a pharmacy dispenses a vial of a
medication (a "multidose vial") that includes more than the
specific dose of the medication required for a patient. one
advisory that we should give the nurse is exactly how to prepare
the medication. A nurse or other caregiver may then be tasked
calculating an appropriate dose of the medication for the patient
based on the total amount of medication included in the vial. For
example, a physician may order that a 65 kg patient receive a 40
unit/kg bolus dose, and the administration of the medication should
be at a rate not to exceed 400 units/minute. The vial of the
medication contains 1000 units/mL. The nurse must manually
calculate the total dose of the vial, namely, that the vial
contains 2600 units of the medication. The nurse must then
determine that this is 2.6 mL of the 1000 units/mL, and then
calculate the dose injection for a minimum time of 6.5 minutes. The
disclosed monitoring system 40 may advantageously provide this
information to the nurse so that the nurse, such as a notification
to remove 2.6 mL of the 1000 units/mL medication and administer at
0. 4 Ml/min, and further provide the syringe label complete with
patient, drug, dose and bar code to the nurse.
[0042] When the prescribed time for delivery of the medication or
medications arrives, the medications are carried to the patient's
area and administered to the patient by the caregiver. In the case
of drugs to be delivered via infusion, the caregiver hangs the
infusion bag and prepares the infusion line, attaches the bag to an
infusion pump 80, and sets up the infusion pump to deliver the
medication by programming the pump with values for various
parameters that are used by the pump to control delivery of the
medication to the patient. When the medication delivery parameters
are entered into the pump, the pump communicates the entered
parameters to the medical entity database 60. In certain aspects,
the monitoring system 40 may, for example, review the medication
delivery parameters and a history of previous medication delivery
parameters entered into the infusion pump 80 to deliver the
medication or similar medications, and determine that alternative
medication delivery parameters should be used. If such a
determination is made, the monitoring system 40 may send a
notification to the infusion pump 80 for the caregiver to view. The
notification can propose, for example, alternative medication
delivery parameters and a reason for proposing the alternative
medication delivery parameters. If the alternative medication
delivery parameters for the infusion pump 80 are accepted, or
alternatively manually overridden, the monitoring system 40 can
send a signal to the infusion pump 80 to begin infusion of the
medication.
[0043] FIG. 2 is a block diagram 200 illustrating an example
monitoring system 40 and server 130 from the architecture of FIG. 1
according to certain aspects of the disclosure. The control system
40, a device 160 (e.g., such as medical device 80), and the server
130 are connected over the network 30 via respective communications
modules 210, 156, and 138. The communications modules 210, 156, and
138 are configured to interface with the network 30 to send and
receive information, such as data, requests, responses, and
commands to other devices on the network. The communications
modules 210, 156, and 138 can be, for example, modems or Ethernet
cards and communicate over a wired or wireless connection.
[0044] The monitoring system 40 includes a processor 212, the
communications module 210, and a memory 42 that includes a
monitoring application 208. The monitoring application 208 includes
instructions for the processor 212 to obtain, from the processor
136 of the server 130, information from the medical entity database
62 over the network 30 using respective communications modules 210
and 138 of the monitoring system 40 and the server 130. The
information received from the medical entity database 62 includes
identification information for a medical entity, courses of action
associated with the medical entity, and a history of the medical
entity. The medical entity can be, for example, a patient, medical
device 80, medical location (e.g., hospital or area within a
hospital, such as an Intensive Care Unit), or medical item such as
a medication or medical. For example, identification information
for a medical entity can be a name or unique identifier for a
patient. A course of action associated with a medical entity can be
providing a prescribed amount of medication to a patient. A history
of a medical entity can be a listing of medications administered
using a medical device 80.
[0045] The processor 212 of the monitoring system 40 is configured
to execute instructions, such as instructions physically coded into
the processor 212, instructions received from software in memory
42, or a combination of both. For example, the processor 212 of the
monitoring system 40 executes instructions from the monitoring
application 208 to receive a first identifier for a medical entity
located in an institution and a second identifier for a first
course of action associated with the medical entity. The first and
second identifiers can be received from the medical entity database
62 over the network 30. The processor 212 of the monitoring system
is also configured to generate, based on a history of the medical
entity and the first course of action associated with the medical
entity, a second course of action for the medical entity, and
provide a notification to the device 160 indicating the second
course of action. The second course of action can be, for example,
an alternative to the first course of action selected in order to
promote a safe or efficient interaction with the medical entity.
The device 160 can be, for example, a caregiver's mobile device, a
medical device 80 at or near a patient's bedside, a display at a
nurse station 44, or a display of the healthcare facility
information system 34, pharmacy information system 36, physician
order entry system 38, or monitoring system 40. The notification
can include a message indicating a purpose for indicating the
second course of action. For example, a notification can be
displayed using display device 214 on a caregiver's mobile device
160 indicating a prescribed amount of medication for the patient is
too high based on the patient's physiological history relative to
administration of the medication, and further indicate an
alternative amount of medication that is appropriate to the patient
based on the patient's physiological history relative to
administration of the medication. The caregiver may then be asked
to confirm or override the alternative amount using an input device
216 of the mobile device 160.
[0046] The first identifier, the second identifier, or the history
of the medical entity can be received from an external data system
(e.g., server 130) in a native message format of the external data
system, and the processor 212 of the monitoring system 40 can be
configured to convert the first identifier, the second identifier,
or the history of the medical entity into an internal messaging
format configured for use with the monitoring system 40. The
processor 212 can be configured to perform the conversion according
to the system and method of converting messages being sent between
data systems using different communication protocols and message
structures described in U.S. patent application Ser. No.
13/421,776, entitled "Scalable Communication System," and filed on
Mar. 15, 2012, the disclosure of which is hereby incorporated by
reference in its entirety for all purposes. The memory 42 of the
monitoring system 40 can include, for example, an interface module
for communicating with the server 130. The interface module can
include information on the communication protocol and data
structure used by the server 130 and is configured to both receive
messages from and transmit messages to the server 130.
[0047] In certain aspects where the medical entity is or otherwise
includes a medical item, the history of the medical entity can
include a number of times the medical item has been dispensed. For
example, the history of the medical entity can indicate that the
psychoactive drug alprazolam has been dispensed by a specific
caregiver over ten times in the past twenty four hours. The first
course of action associated with the medical item alprazolam may
indicate an instruction to dispense alprazolam for a specific
patient, and the second course of action can indicate an
instruction to restrict dispensing of alprazolam (e.g., by locking
the device 160 for dispensing alprazolam), for example, due to the
specific caregiver's abnormally high rate of dispensing of
alprazolam. A notification can be sent to the device 160 for
dispensing alprazolam or the caregiver's mobile device 160
indicating that dispensing of alprazolam has been restricted based
on the caregiver's abnormally high rate of dispensing of
alprazolam. Alternatively, the alprazolam may be removed from the
listing of available medications to the caregiver (e.g.,
"unprofiling" the medication) until a pharmacist or other
authorized caregiver takes appropriate action, such as contacting
the physician or repeating a lab test.
[0048] In certain other aspects where the medical entity is or
otherwise includes a medical item, the processor 212 of the
monitoring system 40 may be configured to receive a third
identifier for a caregiver (e.g., from the medical entity database
62 over the network 30) in the institution. The history of the
medical item can include a level of waste of the medical item by
the caregiver. For example, the history of the medical item can
indicate that it is an antihypertensive that is wasted (e.g.,
dispensed but never used) by the caregiver on average 22% of the
times it is dispensed by the caregiver. The waste may occur due to,
for example, resolution of the condition for which the medication
was prescribed, patient-perceived ineffectiveness, prescription
changes by the physician, and patient-perceived adverse effects.
The abnormally high rate of wastage by the caregiver may be due to
the caregiver being prone to not checking a patient's record before
dispensing a medication. The first course of action associated with
the antihypertensive medication may indicate an instruction to the
caregiver to dispense a ten count of the antihypertensive
medication, and the second course of action can indicate an
instruction to decrease the dispensing count of the
antihypertensive medication to two, or restrict dispensing
altogether, for example, based on the caregivers history of wasting
the antihypertensive medication. A notification can be sent to the
device 160 for dispensing the antihypertensive medication or the
caregiver's mobile device 160 indicating that dispensing of the
antihypertensive medication has been reduced or restricted due to
the caregiver's history of wasting the antihypertensive
medication.
[0049] In certain further aspects where the medical entity is or
otherwise includes a medical item, the history of the medical
entity can include an average amount of time between dispensing of
the medical item and the medical item being administered to a
patient. For example, the average amount of time for dispensing a
solution of adrenaline in an institution is 45 minutes, and a first
course of action associated with the solution of adrenaline is to
dispense the solution of adrenaline according to normal procedures.
The second course of action associated with the dispensing solution
can be to dispense the solution of adrenaline statim (e.g.,
according to expedited procedures) because adrenaline is commonly
needed urgently to administer to a patient and an average wait time
of 45 minutes for the solution is not acceptable. A notification
can be sent to the pharmacy information system 36, nurse station
44, or other device 160 indicating the expedited need for the
adrenaline solution.
[0050] In certain aspects where the medical entity is or otherwise
includes a medical location, such as a ward in a hospital, the
hospital itself, or a campus of multiple hospitals, the history of
the medical location can include, for example, a rate of
improvement of patients associated with the medical location. For
example, the history of the medical location such as a pediatric
intensive care unit (PICU) may indicate a sharp decline in immunity
levels of patients in the PICU. The first course of action
associated with the medical location may indicate an instruction to
order a small amount of a macrolide antibiotic, azithromycin, to
treat immunity deficiency in the PICU, and the second course of
action can indicate an instruction to recommend an increase in the
amount of azithromycin being ordered for the PICU, for example, due
to the sharp decline in patient immunity levels. A notification can
be sent to the pharmacy information system 36, nurse station 44, or
other device 160 indicating the recommendation for the increased
need for azithromycin.
[0051] In certain other aspects where the medical entity is or
otherwise includes a medical location, the history of the medical
entity can include an incidence rate of illness associated with the
medical location. For example, the history of a specific hospital
may indicate that the incidence of the influenza virus has
dramatically increased over the past seven days from an average of
three new influenza cases per day to over twenty influenza cases
per day. The first course of action associated with the specific
hospital may indicate an instruction to order a small amount of an
antiviral drug, oseltamivir, to treat influenza, and the second
course of action can indicate an instruction to increase the amount
of oseltamivir being ordered for the specific hospital, for
example, due to the sharp increase in daily incidence of influenza.
A notification can be sent to the pharmacy information system 36,
nurse station 44, or other device 160 indicating an increased need
for oseltamivir.
[0052] In certain aspects, the processor 212 of the monitoring
system 40 is configured to receive a first identity of a caregiver
at an institution and a proposed course of action for a medical
entity, generate, based on a history of the caregiver within the
institution, a modified course of action, and provide a
notification of the modified course of action to the caregiver. For
example, the history of the caregiver can indicate a level of waste
of a medical item by the caregiver, and the modified course of
action can include an indication of an action to decrease a level
of waste of the medical item by the caregiver. The indicated action
can be, for example, an instruction to reduce the number of the
medical items being dispensed. As another example, the history of
the caregiver can include an identification of one or many error
made by the caregiver with a medical item or patient, and the
modified course of action can include an indication of an action to
decrease a likelihood of the error with the medical item, the
patient, another medical item, or another patient. The indicated
action can be, for instance, an instruction to not perform a
certain action with a patient or medical item, or a suggestion for
additional training.
[0053] FIG. 3 illustrates an example process 300 for facilitating
safe use of a medical item using the example monitoring system 40
of FIG. 2. While FIG. 3 is described with reference to FIG. 2, it
should be noted that the process steps of FIG. 3 may be performed
by other systems. The process 300 begins by proceeding from
beginning step 301 when a request is initiated to perform an action
associated with a medical entity, to step 302 when a first
identifier for a medical entity located in an institution and a
second identifier for a first course of action associated with the
medical entity are received. The medical entity can include at
least one of a patient, medical device, medical location, or
medical item. Next, in step 303, a second course of action for the
medical entity is generated based on a history of the medical
entity and the first course of action associated with the medical
entity. Finally, in step 304, a notification is provided to a
device 160 indicating the second course of action. The process 300
then ends in step 305.
[0054] FIG. 3 set forth an example process 300 for facilitating
safe use of a medical item using the example monitoring system 40
of FIG. 2. An example will now be described using the example
process 300 of FIG. 3, a medical entity that is a medication, a
device 160 that is an infusion pump (e.g., infusion pump 80), and
an error-prone caregiver.
[0055] The process 300 begins by proceeding from beginning step 301
when the caregiver enters parameters into the infusion pump 160 to
administer a medication, to step 302 when a monitoring system 40
receives a first identifier identifying the medication and a second
identifier identifying a first course of action, namely, certain
parameters entered by the caregiver into the infusion pump 160 in
order to administer the medication. Next, in step 303, a second
course of action, namely, a requirement to confirm the medication
parameters before administration, is generated based on a history
of the medication and the entered parameters for administering the
medication. Specifically, the history of the medication indicates
that the caregiver has previously administered the medication
incorrectly 20% of the time. Finally, as provided in the example
illustration of FIG. 4, in step 304, a notification 482 requiring
confirmation from the caregiver is provided for display on the
infusion pump 160. The process 300 then ends in step 305.
[0056] FIG. 5 is a block diagram illustrating an example computer
system 500 with which the monitoring system 40, the device 160, and
the server 130 of FIG. 2 can be implemented. In certain aspects,
the computer system 500 may be implemented using hardware or a
combination of software and hardware, either in a dedicated server,
or integrated into another entity, or distributed across multiple
entities.
[0057] Computer system 500 (e.g., monitoring system 40, the device
160, and the server 130) includes a bus 508 or other communication
mechanism for communicating information, and a processor 502 (e.g.,
processor 212, 154, and 136) coupled with bus 508 for processing
information. By way of example, the computer system 500 may be
implemented with one or more processors 502. Processor 502 may be a
general-purpose microprocessor, a microcontroller, a Digital Signal
Processor (DSP), an Application Specific Integrated Circuit (ASIC),
a Field Programmable Gate Array (FPGA), a Programmable Logic Device
(PLD), a controller, a state machine, gated logic, discrete
hardware components, or any other suitable entity that can perform
calculations or other manipulations of information.
[0058] Computer system 500 can include, in addition to hardware,
code that creates an execution environment for the computer program
in question, e.g., code that constitutes processor firmware, a
protocol stack, a database management system, an operating system,
or a combination of one or more of them stored in an included
memory 504 (e.g., memory 42, 152, or 132), such as a Random Access
Memory (RAM), a flash memory, a Read Only Memory (ROM), a
Programmable Read-Only Memory (PROM), an Erasable PROM (EPROM),
registers, a hard disk, a removable disk, a CD-ROM, a DVD, or any
other suitable storage device, coupled to bus 508 for storing
information and instructions to be executed by processor 502. The
processor 502 and the memory 504 can be supplemented by, or
incorporated in, special purpose logic circuitry.
[0059] The instructions may be stored in the memory 504 and
implemented in one or more computer program products, i.e., one or
more modules of computer program instructions encoded on a computer
readable medium for execution by, or to control the operation of,
the computer system 500, and according to any method well known to
those of skill in the art, including, but not limited to, computer
languages such as data-oriented languages (e.g., SQL, dBase),
system languages (e.g., C, Objective-C, C++, Assembly),
architectural languages (e.g., Java, .NET), and application
languages (e.g., PHP, Ruby, Perl, Python). Instructions may also be
implemented in computer languages such as array languages,
aspect-oriented languages, assembly languages, authoring languages,
command line interface languages, compiled languages, concurrent
languages, curly-bracket languages, dataflow languages,
data-structured languages, declarative languages, esoteric
languages, extension languages, fourth-generation languages,
functional languages, interactive mode languages, interpreted
languages, iterative languages, list-based languages, little
languages, logic-based languages, machine languages, macro
languages, metaprogramming languages, multiparadigm languages,
numerical analysis, non-English-based languages, object-oriented
class-based languages, object-oriented prototype-based languages,
off-side rule languages, procedural languages, reflective
languages, rule-based languages, scripting languages, stack-based
languages, synchronous languages, syntax handling languages, visual
languages, wirth languages, embeddable languages, and xml-based
languages. Memory 504 may also be used for storing temporary
variable or other intermediate information during execution of
instructions to be executed by processor 502.
[0060] A computer program as discussed herein does not necessarily
correspond to a file in a file system. A program can be stored in a
portion of a file that holds other programs or data (e.g., one or
more scripts stored in a markup language document), in a single
file dedicated to the program in question, or in multiple
coordinated files (e.g., files that store one or more modules,
subprograms, or portions of code). A computer program can be
deployed to be executed on one computer or on multiple computers
that are located at one site or distributed across multiple sites
and interconnected by a communication network. The processes and
logic flows described in this specification can be performed by one
or more programmable processors executing one or more computer
programs to perform functions by operating on input data and
generating output.
[0061] Computer system 500 further includes a data storage device
506 such as a magnetic disk or optical disk, coupled to bus 508 for
storing information and instructions. Computer system 500 may be
coupled via input/output module 510 to various devices. The
input/output module 510 can be any input/output module. Example
input/output modules 510 include data ports such as USB ports. The
input/output module 510 is configured to connect to a
communications module 512. Example communications modules 512
(e.g., communications module 210, 156, and 138) include networking
interface cards, such as Ethernet cards and modems. In certain
aspects, the input/output module 510 is configured to connect to a
plurality of devices, such as an input device 514 (e.g., input
device 216) and/or an output device 516 (e.g., display device 214).
Example input devices 514 include a keyboard and a pointing device,
e.g., a mouse or a trackball, by which a user can provide input to
the computer system 500. Other kinds of input devices 514 can be
used to provide for interaction with a user as well, such as a
tactile input device, visual input device, audio input device, or
brain-computer interface device. For example, feedback provided to
the user can be any form of sensory feedback, e.g., visual
feedback, auditory feedback, or tactile feedback; and input from
the user can be received in any form, including acoustic, speech,
tactile, or brain wave input. Example output devices 516 include
display devices, such as a LED (light emitting diode), CRT (cathode
ray tube), or LCD (liquid crystal display) screen, for displaying
information to the user.
[0062] According to one aspect of the present disclosure, the
monitoring system 40, the device 160, and the server 130 can be
implemented using a computer system 500 in response to processor
502 executing one or more sequences of one or more instructions
contained in memory 504. Such instructions may be read into memory
504 from another machine-readable medium, such as data storage
device 506. Execution of the sequences of instructions contained in
main memory 504 causes processor 502 to perform the process steps
described herein. One or more processors in a multi-processing
arrangement may also be employed to execute the sequences of
instructions contained in memory 504. In alternative aspects,
hard-wired circuitry may be used in place of or in combination with
software instructions to implement various aspects of the present
disclosure. Thus, aspects of the present disclosure are not limited
to any specific combination of hardware circuitry and software.
[0063] Various aspects of the subject matter described in this
specification can be implemented in a computing system that
includes a back end component, e.g., as a data server, or that
includes a middleware component, e.g., an application server, or
that includes a front end component, e.g., a client computer having
a graphical user interface or a Web browser through which a user
can interact with an implementation of the subject matter described
in this specification, or any combination of one or more such back
end, middleware, or front end components. The components of the
system can be interconnected by any form or medium of digital data
communication, e.g., a communication network. The communication
network (e.g., network 30) can include, for example, any one or
more of a personal area network (PAN), a local area network (LAN),
a campus area network (CAN), a metropolitan area network (MAN), a
wide area network (WAN), a broadband network (BBN), the Internet,
and the like. Further, the communication network can include, but
is not limited to, for example, any one or more of the following
network topologies, including a bus network, a star network, a ring
network, a mesh network, a star-bus network, tree or hierarchical
network, or the like. The communications modules can be, for
example, modems or Ethernet cards.
[0064] Computing system 500 can include clients and servers. A
client and server are generally remote from each other and
typically interact through a communication network. The
relationship of client and server arises by virtue of computer
programs running on the respective computers and having a
client-server relationship to each other. Computer system 500 can
be, for example, and without limitation, a desktop computer, laptop
computer, or tablet computer. Computer system 500 can also be
embedded in another device, for example, and without limitation, a
mobile telephone, a personal digital assistant (PDA), a mobile
audio player, a Global Positioning System (GPS) receiver, a video
game console, and/or a television set top box.
[0065] The term "machine-readable storage medium" or "computer
readable medium" as used herein refers to any medium or media that
participates in providing instructions or data to processor 502 for
execution. Such a medium may take many forms, including, but not
limited to, non-volatile media, volatile media, and transmission
media. Non-volatile media include, for example, optical disks,
magnetic disks, or flash memory, such as data storage device 506.
Volatile media include dynamic memory, such as memory 504.
Transmission media include coaxial cables, copper wire, and fiber
optics, including the wires that comprise bus 508. Common forms of
machine-readable media include, for example, floppy disk, a
flexible disk, hard disk, magnetic tape, any other magnetic medium,
a CD-ROM, DVD, any other optical medium, punch cards, paper tape,
any other physical medium with patterns of holes, a RAM, a PROM, an
EPROM, a FLASH EPROM, any other memory chip or cartridge, or any
other medium from which a computer can read. The machine-readable
storage medium can be a machine-readable storage device, a
machine-readable storage substrate, a memory device, a composition
of matter effecting a machine-readable propagated signal, or a
combination of one or more of them.
[0066] As used herein, the phrase "at least one of" preceding a
series of items, with the terms "and" or "or" to separate any of
the items, modifies the list as a whole, rather than each member of
the list (i.e., each item). The phrase "at least one of" does not
require selection of at least one item; rather, the phrase allows a
meaning that includes at least one of any one of the items, and/or
at least one of any combination of the items, and/or at least one
of each of the items. By way of example, the phrases "at least one
of A, B, and C" or "at least one of A, B, or C" each refer to only
A, only B, or only C; any combination of A, B, and C; and/or at
least one of each of A, B, and C.
[0067] Furthermore, to the extent that the term "include," "have,"
or the like is used in the description or the claims, such term is
intended to be inclusive in a manner similar to the term "comprise"
as "comprise" is interpreted when employed as a transitional word
in a claim.
[0068] A reference to an element in the singular is not intended to
mean "one and only one" unless specifically stated, but rather "one
or more." The term "some" refers to one or more. All structural and
functional equivalents to the elements of the various
configurations described throughout this disclosure that are known
or later come to be known to those of ordinary skill in the art are
expressly incorporated herein by reference and intended to be
encompassed by the subject technology. Moreover, nothing disclosed
herein is intended to be dedicated to the public regardless of
whether such disclosure is explicitly recited in the above
description.
[0069] While this specification contains many specifics, these
should not be construed as limitations on the scope of what may be
claimed, but rather as descriptions of particular implementations
of the subject matter. Certain features that are described in this
specification in the context of separate embodiments can also be
implemented in combination in a single embodiment. Conversely,
various features that are described in the context of a single
embodiment can also be implemented in multiple embodiments
separately or in any suitable subcombination. Moreover, although
features may be described above as acting in certain combinations
and even initially claimed as such, one or more features from a
claimed combination can in some cases be excised from the
combination, and the claimed combination may be directed to a
subcombination or variation of a subcombination.
[0070] Similarly, while operations are depicted in the drawings in
a particular order, this should not be understood as requiring that
such operations be performed in the particular order shown or in
sequential order, or that all illustrated operations be performed,
to achieve desirable results. In certain circumstances,
multitasking and parallel processing may be advantageous. Moreover,
the separation of various system components in the aspects
described above should not be understood as requiring such
separation in all aspects, and it should be understood that the
described program components and systems can generally be
integrated together in a single software product or packaged into
multiple software products.
[0071] The subject matter of this specification has been described
in terms of particular aspects, but other aspects can be
implemented and are within the scope of the following claims. For
example, the actions recited in the claims can be performed in a
different order and still achieve desirable results. As one
example, the processes depicted in the accompanying figures do not
necessarily require the particular order shown, or sequential
order, to achieve desirable results. In certain implementations,
multitasking and parallel processing may be advantageous. Other
variations are within the scope of the following claims.
[0072] These and other implementations are within the scope of the
following claims.
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